BC ADVANTAGE
May / June 2018 | Issue 13.3
Providing resources for medical practices and the people behind them
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E/M Code Changes in CPT® 2018
Routine Waiver of Patient Out-of-Pocket Expenses
Coding for Strains in ICD-10
The to Face of Your Practice – Great Customer Service My Secrets Marketing to Doctors – Part I
Creating a Culture of
Compliance
in 2018
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CEO Letter Here we are; almost halfway through the year. I hope that 2018 has been kind to you so far, but since we’re in the last throes of winter (yes, it was 29 degrees here last night and we lost all of our apple blossoms from our trees!), I am just craving warmer weather. I do not know how the Northerners can cope with such temperatures and am very thankful to live in the South. Speaking of South, we just returned from the Healthcon Conference in Orlando, FL. We also spent some time in Columbus, OH for the OHIMA conference as well just before that. It has been so nice catching up with subscribers and chatting with you all. (Some big congratulations go out to our winners of the healthy snack baskets too!) Please know that I always welcome the good, the bad, and the ugly comments, thoughts, or suggestions from you, our esteemed readers, on how to make our services for you better. Get in touch. Let me know. I’m listening! I do have a request for you as we need to know what you want to read about in BC Advantage! Check out our Facebook page for the pinned post at the top for instructions on how to make your suggestions and about the giveaways! Onto this issue: Sean Weiss and Frank Cohen have written the cover this issue about creating a culture of compliance in 2018. There are many buzz words floating around right now, with “risk-based auditing” as a front runner and something that is well worth learning about. As always, we have awesome articles for you and I really hope that you’re reading and enjoying them. Jessica Gustafson, Esq. and Adrienne Dresevic, Esq. have written on some softening by the DOJ regarding federal agency guidance documents. Rachel Rose, JD, MBA, has written about legal hold and e-discovery. Two very important topics to learn about. Patrick Phillips has written about marketing your billing service to doctors. It’s hard to get in to see them so you need to be creative and position yourself well. This is part one, so keep an eye out for the follow-up! L.E. Shepherd is also back with another awesome article in his “Thoughts Had…Lessons Learned©” series about the business of medicine. Yes, even though physicians are about their patients and providing great care for them, they are still a business with bills and overheads to allow for, and staff to pay. It’s a great read. Deb Jones is back with another great article on coding pectoralis major muscle tears. Pray you never get one of those—they sound so painful! This issue also offers informative articles on waiving co-pays, ICD-10 updates for 2018, how to become a practice management consultant, and 10-steps for successful recruiting! It just keeps getting better! Keep an eye out for the giveaway in the Health at Your Desk article and enjoy the issue! Until next time,
Storm Kulhan BC Advantage is published bimonthly by Billing-Coding, Inc P.O. Box 80669 Simpsonville SC, 29680
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CONTENTS
MAY / JUNE 2018 - ISSUE 13.3
FEATURES
COVER
REGULARS
10. E/M Code Changes in CPT® 2018
26. Creating a Culture of Compliance in 2018
8. NEWS
14. Coding for Strains in ICD-10: New England Patriots Linebacker Diagnosed with Pectoralis Major Muscle Tear
32. What is a Legal Hold and e-Discovery Anyway?
18. So You Want to Be a Practice Management Consultant? 20. Routine Waiver of Patient Outof-Pocket Expenses 24. 10 Tips for Successful Medical Practice Recruiting
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36. Thoughts Had … Lessons Learned ©: The Business of Medicine 38. My Secrets to Marketing to Doctors – Part I 42. Hendrick Health Says Investment in Employee Training Pays Off in Terms of Loyalty and Improved Patient Care 44. The Department of Justice Softens its Stance on the Applicability of Federal Agency Guidance Documents
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35. Datebook 48. Health at Your Desk 50. Review Incident-to and Split/Shared Services - eBook with Webinar
EXPERT Contributors this issue Jessica L. Gustafson, Esq. is a founding shareholder of The Health Law Partners, P.C. Ms. Gustafson represents hospitals, health systems, hospices, home health agencies, physicians, and other health care providers and suppliers in an array of health care legal matters Adrienne Dresevic, Esq. is a Founding Shareholder of The Health Law Partners, P.C. Practicing in all areas of healthcare law, she devotes a substantial portion of her practice to providing clients with counsel and analysis regarding compliance, Stark Law, Anti-Kickback Statute, and compliance related issues. Debbie Jones, CPC, CCA, currently works as an administrative specialist for CertificationCoachingOrg (cco.us) and writes healthcare-related articles for various companies. In addition, she has a new blog called Medical Coding Buff. Regina Mixon is the CEO of The Physicians Practice S.O.S. Group and is committed to helping healthcare providers across the country with new practice startups, IRO needs, and providing practice management and compliance solutions. Call our office to discuss any needs you might have.
BC ADVANTAGE
March / April 2018 | Issue 13.2
Providing resources for medical practices and the people behind them
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Patrick Phillips is the Chairman of the Medical Revenue Management Association of America, the nation’s largest network of Certified Medical Revenue Managers (CMRMs). He is Founder and CEO of American Business Systems and is the author of Cash Crunch to Cash Flow and his most recent book, The New Thriving Medical Practice, with Dr. Vicki Rackner. Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS, has been a coder for over 25 years with her most recent position being held at Change Healthcare as the Facility Coding Services Line Manager. She has many years of experience in several different areas of coding and serves as an interim instructor in her hometown of Mobile, AL. Rachel V. Rose, JD, MBA, is a Houstonbased attorney advising on federal and state compliance and areas of liability associated with a variety of healthcare, legal, and regulatory issues including: HIPAA, the HITECH Act, the False Claims Act, Medicare issues, women’s health, as well as corporate and security regulations. L. E. Shepherd, Jr. MSA, CHBC, is the CEO of MedBizonics, LLC. He is a Certified Healthcare Business Consultant (CHBC)
No Therapy Cap Exceptions for 2018
Laboratory Fee Schedule Takes A Big Hit In 2018
Documentation that Serves a Purpose
member of the National Society of Certified Healthcare Business Consultants (NSCHBC). He has written extensively on practice, financial, and tax management topics for various medical and dental publications. Linda Walker is the owner of Practice Managers Resource and Networking Community. She has almost 30 years of health insurance and medical claims experience and is focused on providing the most up-to-date resources and services to the medical billing industry and promises to deliver the most honest and ethical services to her members. Sean M. Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC is a Partner and Vice President of Compliance at Doctors Management. Sean has dedicated his career to helping healthcare facilities reduce the risk of noncompliance and achieve measurable financial results. An accomplished compliance and management professional. Frank Cohen is the Director of Analytics and Business Intelligence at Doctors Management. Frank’s expertise includes data mining, applied statistics, and predictive analytics. In addition, he provides compliance risk analysis and meaningful assistance to healthcare organizations in the areas of process improvement, compliance, quality, and profitability.
Face of Your Great Customer Service How toThe Code Screening andPractice Diagnostic–Colonoscopy
GET PUBLISHED The Importance of Accuracy in
Diagnostic Documentation Exclusive Interview with and Coding Dr. David S. Nilasena Chief Medical Officer, CMS Dallas
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We are always interested in hearing from any industry experts who would like to get published in our national magazine. Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.
Mary Pat Whaley, FACMPE, CPC, is the founder and president of Manage My Practice, the small practice resource center. With 30+ years managing physician practices of all sizes and specialties in the private and public sectors, Mary Pat Whaley is one of the preeminent practice management consultants in the United States today.
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ADVERTISING Index This index is provided as a service to our readers. Please visit their websites listed below, and let them know you saw their advertisement in BC Advantage magazine and for any discounts offered. For more information on these advertisers, go to www.billing-coding.com/MEDIAPLANNER COMPANY WEBSITE PAGE # 1st Healthcare Compliance www.1sthcc.com 9 AAPC www.aapc.com 7 AHIMA www.ahima.org 13,25 Appeal Training www.appealtraining.com 31 BC Advantage Audio www.bcadvantageaudio.com 41 DoctorsManagement www.doctors-management.com 2 eBridge www.ebridge.com 29 Medco Consultants www.medcoconsultants.com 35 NAMAS www.namas.co 47 Optum360
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Advancing the Business of Healthcare
Includes 2018 Guidelines in 1st Edition!
We Heard You Loud and Clear AAPC 2018 Code Books are New and Improved
You asked, we listened. Our 2018 code books are far superior to anything we’ve ever developed. Thanks to you. In addition to being higher quality, we’ve added these features: More Color
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Guide to Switching Practice Payment Systems Is It Time for a Switch? Revenue Cycle is More Than Payments! The right revenue cycle partner operates as a trusted advisor and resource, helping providers find custom revenue cycle solutions to meet the needs of patients and practices. Download our guide today to learn what to look for in a revenue cycle partner and how to manage a smooth transition when making the switch to a new provider. Topics addressed in this Guide: • Standards to look for in customer service and security • Criteria for researching vendors • Step by step best practices for switching revenue cycle systems http://go.ntctexas.com/guide-to-switching-medical-practice-payment-systems
CMS Hints at Blue Button 2.0 Mandates for Medicare Advantage Plans in 2020 The Centers for Medicare & Medicaid Services (CMS) is considering a mandate for Medicare Advantage plan sponsors to adopt data-sharing platforms that can interact with Blue Button 2.0 beginning in 2020. For now, the agency “encourages” health insurers to use data release platforms for members that “meet or exceed the capabilities of CMS’s Blue Button 2.0,” according to an announcement (PDF) this week that raised MA payment rates 3.4% in for fiscal year 2019.
Unveiled at the HIMSS18 annual conference last month, Blue Button 2.0 uses Fast Healthcare Interoperability Resources (FHIR) standards to allow app developers to deliver Medicare claims to beneficiaries. Following a speech in which she called on insurers to “give patients their claims data electronically,” CMS Administrator Seema Verma told a group of reporters that the agency would be “evaluating every single relationship” with insurers, including changes to the Medicare Advantage star-rating program. Source: fiercehealthcare
New Behavioral Health Coding Course Online Through AAPC This online course is designed for professional coders interested in the Behavioral Health specialty and includes foundational material on common diagnoses and treatments in the field. Cases and examples taken from real world, redacted behavioral health records are utilized throughout the course. Students will learn Evaluation and Management, CPT®, and ICD-10-CM coding and guidelines specific for behavioral health and substance abuse treatment. Requirements of provider documentation for this specialty are also discussed to provide a basis of knowledge for working as a coder in a behavioral health setting. *Completion of a professional coding course, or 1 year of ProFee coding experience recommended as a prerequisite. Behavioral Health Coding - $299.00 (Members: $249 ) - Enroll Now - www.aapc.com
Correction! The BC Advantage team would like to apologize to L.E. Shepherd and our readers regarding an article that was published in Issue 13.2-March/April 2018. The article was titled: Thoughts Had…Lessons Learned© Provider Production Optimization and was written by L.E. Shepherd. In the Adam Smith chart that was used to portray Capital vs. Labor costs on page 33 of that issue, we unfortunately reversed the arrows indicating time and compensation within the graphic. It should show time pointing toward the Company (products) and Compensation pointing towards Works (labor). We have fixed it to read correctly online and apologize for the error.
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Written by our “dream team” of healthcare providers and attorneys, The Fundamentals Course is packed with useful, easy-to-understand information that covers HIPAA, OSHA, employment law and enforcement of Federal healthcare laws.
Visit 1sthcc.com/shop and use BCADVANTAGE10 for an exclusive 10% discount! acceptable to document codes instead of diagnoses. ICD-10-CM should have been reported, e.g., K70.30, Alcoholic cirrhosis of liver codes “without narrative are not acceptable to report in place without ascites. Specificity is one of the tenets of ICD-10-CM, and of a diagnosis to support a CMS-HCC. It is the codes that are pull-down menus often lead to a generic code choice. We are validated the medical record written documentation. instructed by the guidelines that “Codes titled ‘unspecified’ are The CMS finalized a rule Monday giving Medicare Advantage plans a being 3.4% pay hike inin2019. That’s well above the 1.84% bump the” A diagnostic allows a provider describe the quality, for use when theproposed information the medical insufficient agency initially and in higher that therecord 2.95% is increase for 2018. The CMS isnarrative also moving forward with to plans to increase the use duration, severity, and context of a comorbidity. A diagnostic code to assign a more specific code. ” Commonly, nonspecific codes of encounter data to determine risk scores for plans. As a result of the finalized rule, 75% of Medicare Advantage risk scores will be fails to capture the nuances of text. E11.9, for example, describes have a lesser risk-weight than specific ones. If the providers in based on traditional fee-for-service data, and 25% based on encounter data. That differs from 2018, when the agency used a risk score “type 2 diabetes without complication.” In narrative, however, the the office do not have access data to the full code set and are not blend of 85% fee-for-service and 15% encounter data. Stakeholders such as the American Hospital Association have pushed back same patient may be described as “handing a new diagnosis well, trained ICD-10-CM code lookup, it may be Government best if they focus at usinginencounter data after a January 2017 Accountability Office report found such information often isn’t accurate. testing four times a day with a low-vision meter, and has experitheir efforts on their documentation, and let the coders abstract “Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased enced relatively few episodes of hypo- or hyperglycemia.” the diagnoses. percentage of encounter data in the blend,” the agency said in a release. The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Causal Relationships And “Due To” An ICD-10-CM Is into Notone a Diagnosis Instead, they’ll beCode locked pharmacy or prescriber for Medicare Part D benefits. Source: modernhealthcare The physician documents that the patient has neuropathy on page A/P: E11.621, L97.412; 3.2 cm X 2.8 cm wound debrided and 4 of a medical record, and on page 6 for the same date of service dressed. RTC in two weeks. identifies that the patient also has diabetes. While the neuropathy is due to sequela of chemotherapy, this is not noted in the record. The above note identifies treatment of a type 2 diabetes patient Winner, Winner, Winner with a diabetic foot ulcer of the right heel, with the fat layer A major change to how documentation and abstraction of causal exposed. The size of the wound is documented, and the patient Congratulations goes to Lesley O. from CO who won a 12-month subscription relationships occurred in the 2017 guidelines, when hundreds will return to the clinic in two weeks for further treatment. to BC Advantage magazine and a basket full of tasty, healthy freeze-dried of diagnostic pairings were identified as causal, even if the phyYet, no diagnosis can be abstracted from this documentation. snacks (sponsored by Health at Your Desk) at Healthcon! sician does not document them as etiology and manifestation. The 2017 Contract-Level RADV Reviewer Guidance states it is not
CMS Gives Medicare Advantage Plans a Raise
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E/M Code Changes in CPT® 2018
It is that time of year again! The time to throw out the old and bring in the new. With the release of the CPT 2018 updates, we will see major changes in coding throughout the E/M section. During the update, many new codes and chapters were added to allow for Collaborative Care Management and new Behavioral Health Management codes. in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements…. Typically 50 minutes are spent face-to-face with the patient and/or family or caregiver. Guideline: Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. This service includes a thorough evaluation of medical and psychosocial factors, potentially contributing to increased morbidity. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management code. A single physician or other qualified health care professional should not report 99483 more than once every 180 days.
T
his article will guide you through the complex changes that occured January 1, 2018. Cognitive Assessment and Care Plan Services Added
99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian,
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New code 99483 Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements…. Typically 50 minutes are spent face-to-face with the patient and/or family or caregiver replaces HCPCS G0505. Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition. This service includes a thorough evaluation of medical and psychosocial factors,
potentially contributing to increased morbidity. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management code. Cognitive assessment and care planning may be reported every 180 days. Do not report with other E/M services. Psychiatric Collaborative Care Management Services Added Three new codes (99492-99494) report initial and subsequent psychiatric collaborative care management (CoCM). Per the American Psychiatric Association, CoCM services: …typically [are] provided by a primary care team consisting of a primary care physician and a care manager who work in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. To report CoCM, all of the bulleted items must be performed and documented, and the time threshold must be met, as demonstrated in the chart, below. Do not report 99492 and 99493 within the same calendar month. See table on page 12 New Codes for General Behavioral Health Integration Care Management New code 99484 Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements… replaces HCPCS code G0507 to report general behavioral health integration (BHI) services, which incorporate principles associated with collaborative care. To report these services, all bulleted items listed in the code descriptor must be performed and documented, and the time threshold (in this case, at least 20 minutes of clinical
staff time, directed by a physician or other qualified health care professional, per calendar month) must be met. Do not report 99484 with 99492, 99493, 99494 (see above) in the same calendar month. Anticoagulation Management Gets an Overhaul Codes 99363 and 99364 for anticoagulation management are deleted and replaced by new (medicine section ) codes 93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/caregiver’s ability to perform testing and report results and 93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed. Due to the critical nature of thinning blood or reducing its clotting factor, patients on warfarin require constant oversight, along with International Normalized Ration (INR) testing. The medication is adjusted, as needed, to provide the best level of anticoagulation in the blood. The patient is reminded of the specific dietary needs, and observed for possible bruising. Anticoagulation management codes are used to report this oversight, which includes ordering, review, and interpretation of the INR testing, communication with the patient, and dosage adjustments, as necessary. Code 93792 reports the education for the patient or caregiver for home INR monitoring, while 93793 reports the provider’s management and oversight. Revised Guidelines for Initial Observation Care and More New text clarifies that initial observation codes 9921899220: … report the encounter(s) by the supervising physician or other qualified healthcare professional with the patient when designated as a hospital “observation status.” This refers to the initiation of observation status, supervision of the care plan for the observation, and performance of periodic reassessments. For observation encounters by other
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physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care (99224-99226) as appropriate. The term “outpatient hospital” is added to code descriptors to clarify that observation services (including observation care discharge, 99217) are specific to outpatient status (POS 22). Do not report observation for patients admitted to the hospital. There are several important changes to E/M section guidelines and parenthetical instructions. New guidelines clarify that prolonged service codes 99354-99357 involve direct patient contact, beyond the usual service, in either the inpatient or outpatient setting. The guidelines define direct patient contact as “face-to-face,” but further including “additional nonface-to-face services on the patient’s floor or unit in the hospital or nursing facility during the same session.” New guidelines state that telephone services code 99441-99443 are not reported with 93792, 93793 for home and outpatient INR monitoring. Revised guidelines clarify that time-based critical care services (99291, 99292) may not be reported by the same individual (or a different individual of the same
specialty or group) when reporting neonatal or pediatric critical care services (99468-99476) for the same patient on the same day. But, 99291 and 99292 may be reported by an individual of a different specialty (from either the same or different group) on the same day as neonatal or pediatric critical care services. Further, per CPT®, “Critical care interfacility transport face-to-face (99466, 99467) or supervisory (99485, 99486) services may be reported by the same or different individual of the same specialty and same group, when neonatal or pediatric critical care services (99468-99476) are reported for the same patient on the same day.”
Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS, has been a coder for over 25 years with her most recent position being held at Change Healthcare as the Facility Coding Services Line Manager. She has many years of experience in several different areas of coding and serves as an interim instructor in her hometown of Mobile, AL. Pritchett has owned and operated her own medical billing and coding company, Gulf Coast HIM Solutions, located in Mobile, AL. She shares her expertise in publications and as a lecturer at conferences, such as HealthCon, and Coding-Con for The Coding Institute. She has served as the president, vice president, and Member Development and Education officers of the Mobile, AL local chapter.
Total Duration of Collaborative Care Management Over a Calendar Month
Type of Service
Code(s)
Initial - 70 minutes
Less than 36 minutes 36-85 minutes (36 minutes = 1 hour 25 minutes)
Not reported separately 99492
Initial plus each additional increment up to 30 minutes
86-116 minutes (1 hr. 26 minutes - 1 hr. 56 minutes)
99492 x 1 AND 99494 x 1
Subsequent 60 minutes
Less than 31 minutes 31-75 minutes (31 minutes - 1 hr. 15 minutes)
Not reported separately 99493
Subsequent plus each additional increment up to 30 minutes
76-105 minutes (1 hr. 16 minutes - 1 hr. 45 minutes)
99493 x 1 AND 99494 x 1
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Coding for Strains in ICD-10: New England Patriots Linebacker Diagnosed with Pectoralis Major Muscle Tear You may or may not know of Dont’a Hightower. However, if you are a football fan, and in particular, a New England Patriots fan, you probably know Hightower is a linebacker for their team. Last year, Hightower injured himself during a game and was diagnosed with a pectoral major muscle tear, according to Dr. David Chao, an orthopaedic surgeon and sports medicine specialist.
A
lthough this type of injury is rare, it is becoming more common as more individuals participate in physical exercise and high-impact contact sports, such as football and
•
weightlifting. • According to the National Institutes of Health, a review was carried out on 20 patients who had a pectoralis major muscle repair between 2003 and 2011, and the results were as follows: •
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All patients were men with an average age of 30
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years (ages 20-55) when injured. 60% of the patients suffered injury while bench pressing, and 15% of the patients. suffered while wrestling. Other mechanisms of injury included throwing a football and jet skiing. Average time from injury to surgical repair was 3.8 months.
The pectoralis muscles are sometimes referred to as “pecs,” “chest muscle,” or “pectoral muscle” by body builders and sports athletes. This muscle is a thick, fan-shaped muscle that lies on the front of the chest under the breast and
makes up the bulk of the chest muscles. Under the pectoralis major is the pectoralis minor, which is a thin, triangular-shaped muscle. The pectoralis major attaches to the upper bone of the arm, called the humerus, and is divided into two parts. The clavicular head makes up the upper part, and the sternal head makes up the lower part. The muscle fibers of the pectoralis end in a flat tendon, which is inserted into a groove called the intertubercular sulcus, in the upper humerus located in the upper arm. The pectoralis major controls various actions in order to move the shoulder joint: • • • •
Clavicular head flexes the humerus, as in throwing an underhand ball Sternocostal head adducts the humerus, as when flapping the arms Pectoralis major medially rotates the humerus, as when arm wrestling Pectoralis major keeps the arm attached to the trunk
The pectoralis major may tear or rupture in various parts of the muscle, with the most common being a rupture of the tendon off the humerus bone. Other parts of the muscle where tears may occur are within the muscle belly itself or at the junction of the muscle and tendon (musculo-tendinous junction). The muscle can also tear off the sternum, but this is quite rare, according to Michele R. Berman, M.D. A patient who has had a rupture of the pectoralis muscle may complain of a sharp tearing sensation. When he attempts to rotate his arm inward and toward his chest (adduction and internal rotation), there will be resistance. The shoulder may also be painful and weak. On examination, there will be swelling and bruising, palpable effect and misshapen anterior axillary fold, weakness with adduction and internal rotation.
A partial rupture or an injury that basically tears in the muscle may not require surgical treatment. Instead, a sling may be used to immobilize the injury, along with ice, rest, and Advil for pain relief. If the tendon has been torn away from the bone, surgical treatment is recommended, especially when it involves high-level athletes. An MRI (magnetic resonance imaging) is typically done to make the diagnosis, and the earlier the surgery, the better the outcome, according to the National Institutes of Health. ICD-10-CM Coding According to the ICD-10-CM Official Guidelines for Coding and Reporting, an acute traumatic tear or rupture of a muscle or tendon is classified as a strain (think sTrain = tendon/muscle/fascia). A strain may be an overstretched muscle or a partial or complete tear. These types of injuries are found in Chapter 19 Injury, poisoning, and certain other consequences of external causes (S00-T88). Within this category, injury codes are broken down by body part, type of injury, and in some cases, laterality. The episode of care will also need to be reported and assigned as the 7th character to show “A” (initial encounter), “D” (subsequent encounter), or “S” (sequela). Whenever possible, you should report the cause of injury, place of occurrence, and activity leading up to the injury. These codes may be found in Chapter 20. Note: A sprain is different than a strain. A sprain is an injury to a ligament or joint, and codes for strains and sprains are found in two different categories. A coding example: A 28-year-old male presents to the outpatient clinic today with swelling and bruising over the anterior wall of right axilla. Patient is an amateur weightlifter who was performing his routine workout at the gym when he suffered severe pain and tearing sensation over the right side of the chest. He had tenderness, altered anterior axillary fold crease, and limited movement of his right arm. An MRI (magnetic resonance imaging)
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was recommended due to suspected muscle tear, and he was subsequently diagnosed with tear of tendon of pectoralis major muscle.
A note at Y92 indicates “The following category is for use, when relevant, to identify the place of occurrence of the external cause. Use in conjunction with an activity code.
ICD-10-CM codes assigned: • •
•
S29.011A - Strain of muscle and tendon of front wall of thorax, initial encounter Y92.39 - Other specified sports and athletic area as the place of occurrence of the external cause Y93.B9 - Activity, other involving muscle strengthening exercises
First of all, as a coder, we need to know the pectoralis major muscle is located in the upper chest, or thorax. Without this knowledge, it would be difficult to choose the correct code since there is no listing in the Index for pectoralis major muscle. When looking up the term Strain, muscle (tendon) in the Alphabetic Index, it refers us to Injury, muscle, by site, strain. Under Injury, muscle, thorax, strain, front wall, it provides code S29.011. Verified in the Tabular, S29.011 is Strain of muscle and tendon on front wall of thorax. This code is not reportable, however, as there is a note at S29 to add the appropriate 7th character. The patient is being actively treated, so “A” (initial encounter) needs to be appended, making it S29.011A. There is also a note at S29 to “Code also any additional open wound (S21.-).” In this case, there is no documentation of an open wound. At S00-T88, there is a note to “Use secondary codes from Chapter 20, External causes of morbidity, to indicate cause of injury.” Look in the External Cause of Injuries Index under Place of occurrence, gymnasium Y92.39. This can be verified in the Tabular under Y92.39 - Other specified sports and athletic area as the place of occurrence of the external cause.
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Place of occurrence should be recorded only at the initial encounter for treatment.” In the External Cause of Injuries Index, see Activity (involving) (of victim at time of event), exercise(s), muscle strengthening (non-machine) NEC Y93. B9. This can be verified in the Tabular under Y93. B9 - Activity, other involving muscle strengthening exercises. A note at Y93 indicates, “These codes should be used in conjunction with codes for external cause status (Y99) and place of occurrence (Y92). Since there is no documentation as to the status, we cannot assign a Y99 code. Remember that external cause codes are never assigned as a principal diagnosis. In summary, pectoralis major muscle tears are rare injuries, but they are becoming more common as more individuals take part in high-impact sports and weightlifting. As coders, we need to understand the terminology and anatomy of the pectoralis major muscle and be able to code for related injuries. We also need to know that an acute traumatic tear or rupture of a pectoralis major muscle is classified as a strain and not a sprain. Finally, we should assign as many external cause codes as needed to tell the whole story.
Debbie Jones, CPC, CCA, currently works as an administrative specialist for CertificationCoachingOrg (cco.us) and writes healthcare-related articles for various companies. In addition, she has a new blog called Medical Coding Buff (medicalcodingbuff.com).
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Billing / Coding
So You Want to Be a
Practice Management Consultant? I recently was asked how to start consulting in the medical practice management space. I love consulting, but it’s not nearly as glamorous and freewheeling as it might look. • • • •
Get consulting agreements. Collect deposits. Consult and write a report on your findings and recommendations. Bill and collect your fee.
I started my blog in 2008 with the idea that I might someday leverage it into an income stream. I was told then, and believe it holds true today, that producing good-quality content is the best form of advertisement for consultants. I get 90% of my business through my blog, which ranks well, because I’ve been writing faithfully for 10 years. Independent Consultant Advice
D
on’t Quit Your Day Job
Unless you have an amazing referral stream or money to put into marketing, you cannot expect to be able to support yourself initially. I consulted informally on the side for years before starting my actual consulting practice, and after 6 years of pure consulting, I’ve gone back to having a day job managing a practice and consulting on the side. Write Every Day Consultants write reports. Every day. It’s our product. If you don’t write well or have trouble with spelling or grammar, get help. If you’re not sure if you can write well, get help. Consultants Have to Market Themselves As an independent consultant, you have to wear every hat. You have to: • Market yourself.
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Start or continue consulting if opportunities are available and give more than you get in service and value to help build word-of-mouth. Get testimonials and clients willing to act as referrals. Get a website. Everyone who considers hiring you wants to see that you are “real” and a website is one measure of real. If you teach yourself how to create a website, you will save money and not have to rely on anyone else to correct mistakes or publish a post when you want it published. Develop your voice by producing content for your website—and don’t be afraid that by writing content, you are giving away your secrets. Your secret sauce is who you are and the skill you bring to the table. Troll listservs for problems practices are talking about. Don’t be afraid to answer questions on listservs (your state MGMA listserv, for instance) and build your reputation as a go-to consultant.
Make sure to offer email subscriptions to your website so you are pushing content to your audience. Pay attention to what content does well (Google Analytics is free) and adjust your writing appropriately. Make one article or blog post work three times – where else can you publish it? LinkedIn? Facebook? A practice management newsletter? Expand it into a white paper or eBook? A webinar? Consider offering something for free – a free 30-minute consultation is a great way to introduce potential clients to you. Be a Consultant with a Firm Many consultants “pay their dues” by joining an established consulting company for two or more years. This gives you great experience and can be great money, but you don’t get paid if there’s no work and the traveling is tough after a while. You have to be a real road warrior to travel every Monday through Thursday and only be home on the weekends. I am at the point in my consulting career that I don’t travel. Clients prefer the faceto-face, but once I point out how much money I save them by not traveling to their location, they are fine with it. Put a recording or a video on your website to introduce yourself so potential clients can see and hear you and get a feel for who you are. Blog Monetization I’ve tried every possible way to monetize my blog (ads, products, sponsored content and campaigns, affiliate marketing) and once you have eyeballs on your site, they will produce small income streams but
not significant ones unless your website is drawing thousands of visitors per day. I even considered a paywall at one time, but after market research decided that practice managers and practices would not be willing to pay even a small amount per month for exclusive content. Create a Product Because medical practices—especially small and non-surgical/procedural practices—are really hurting financially, you may want to develop products to sell as well as your time and expertise. One of my niches is implementing Credit Card on File. Practices may have the resources to implement the program themselves, so I also sell an Action Pack of templates and worksheets so they can DIY.
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Develop Your Specialty
Categories:
Think about your experience and skills, and research who is filling a niche that you’d like to develop. Do your homework and see if you can either emulate what they’re doing, or provide something different or better. Think about how you can distinguish yourself in that niche and write, write, write! Write about it so you can be found.
• • • • • • • •
Mary Pat Whaley, FACMPE, CPC, is the founder and president of Manage My Practice, the small practice resource center. With 30+ years managing physician practices of all sizes and specialties in the private and public sectors, Mary Pat Whaley is one of the preeminent practice management consultants in the United States today. In addition to her Board Certification in Medical Practice Management, she is also a Certified Professional Coder and a Fellow in the American College of Medical Practice Executives.
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Routine Waiver of
Patient Out-of-Pocket Expenses Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient’s co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations. For the most part, physicians don’t intentionally set out to break the laws or rules by waiving patients’ out-of-pocket expenses.
H
owever, a medical practice can be contracted with a particular carrier or insurance plan and a patient may still need to meet a high deductible, co-payment, or coinsurance. Many participating provider contracts require participating providers to submit claims directly in exchange for receiving a discounted rate (fee schedule). It is important to first remember that this contract exits only between
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the provider/practice and the insurance carrier. Likewise, a patient’s policy is between the insurer and the plan beneficiary. Much of the conflict arises out of how Federal and State laws co-exist with insurer contracts and out-ofnetwork insurers and how all of the rules and regulations collide with the common intentions of the Federal AntiKickback Statute along with the False Claims Act.
Federal Anti-Kickback Statute Federal law states, “Whoever knowingly and willfully offers or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly… in cash or in kind, to any person to induce such person to refer an individual [for] any item or service for which payment may be made … under a Federal health care program … shall be guilty of a felony..”1
In the example above, Dr. Jones is knowingly waiving Mrs. Smith’s deductible even before the claim is submitted. Thereby any claim submitted without respect to showing the “discount” or “waiver” of deductible is considered a false claim; likewise, this can also be a violation of the Federal Anti-Kickback Statute since the patient is being enticed by the waiver to return to Dr. Jones. Non-Government Plan Claims
In regards to the waiver of patient out-of-pocket, the Federal Anti-Kickback Statute can mean that providers waiving a patient’s government health plan out-of-pocket deductible, co-payment, or coinsurance is indeed an enticement, meaning that it entices the patient to come back to the provider in hopes of having no cost-sharing obligation. False Claims Act The Federal False Claims Act states, “Any person knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval”: (1) the terms “knowing” and “knowingly”— (A) mean that a person, with respect to information— (i) has actual knowledge of the information; (ii) acts in deliberate ignorance of the truth or falsity of the information; or (iii) acts in reckless disregard of the truth or falsity of the information; and (B) require no proof of specific intent to defraud;2 In looking at part B, simply put, a provider may not have to intend to defraud; they need only “act” in disregard to the Federal False Claims Act. To explain further, the following is an example of how a provider can violate the False Claims Act by merely waiving a patient’s Medicare deductible. Mrs. Smith asks Dr. Jones if they can avoid her annual deductible prior to her visit. Dr. Jones assures her that it would be ok to do so. He in turn instructs his billing department not to bill Mrs. Smith after Medicare has sent payment.
Providers that sign contracts with insurers and are considered “In network” will often have a contract with the insurer that states they will accept a negotiated or “participating” rate thereby known as the “plan allowable.” These contracts allow for patients’ claims to be processed using an allowable fee schedule the provider has agreed to, but take into account a patient’s out-of-pocket deductible, co-payment, and/or coinsurance. A patient is still obligated under their policy, as well as the provider’s contract with their insurer, to pay their out of pocket “cost sharing” in order for benefits to be paid. When a provider decides to waive the out-of-pocket expenses without offering the insurance carrier the same courtesy discount, it can easily be considered as insurance fraud because the discount was not provided to the insurance in turn. This could potentially violate the patient’s sharing portion of their policy and a provider’s in network contractual agreement. The same dilemma exists for “out of network providers” if a provider waives a patient’s out-of-pocket expenses, since, again, an insurer is not being billed the same amount as the patient. This could be construed as submitting a false claim if the provider has agreed to only accept what the insurance carrier has paid. Private insurance companies have been successful in both state and federal courts with medical providers and facilities for failure to collect a patient’s out-of-pocket cost sharing. An example is a case from March of 2015 where North Cypress Medical Center filed suit against CIGNA for
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failure to pay claims. In turn, Cigna filed a countersuit (to which they won) because North Cypress failed to attempt at collecting patient deductibles and other out-ofpocket expenses. Case: 12-206953 Is there a proper way to offer a patient with insurance a discount or waive their out-of-pocket expenses?
Got a billing question? Ask the experts at PMRNC Linda Walker linda@billerswebsite.com www.billerswebsite.com
Yes there is, but there must be an established office financial policy for which billing personnel can refer to when a patient requests a discount or the waiver of their patient responsibility. The office financial policy should include written procedures on how a patient may qualify for a “hardship” discount or waiver of their out-of-pocket. Medical offices that have one financial plan can refer patients to their procedure on establishing how a patient would qualify for such a hardship exemption. Since Federal laws state the “routine waiver” of patient deductibles, co-payments, and coinsurance, it is wise for the practice to establish these hardship cases on a case-by-case need as well as on a scale that meets the financial hardship criteria set by the office. The patient’s file should clearly be documented with the details of the hardship and include their signed agreement of hardship. These hardship cases should come into consideration once an insurance claim is processed. Without a documented financial hardship agreement, the procedure should be to file the claim with the proper procedures and should reflect the exact charge the patient would pay. Likewise, the procedures can be billed showing the practice’s actual charge, but it must show the discount so that in turn, the insurance carrier is given the
same discount. This is where it gets tricky. The insurance carrier is still only going to pay their portion and the patient is still going to be responsible for any coinsurance, deductible, and/or co-payment. This puts the office right back where it started. In conclusion, it is always recommended that healthcare providers and facilities have established clear and definitive financial policies to accommodate all patients fairly. In addition to Federal laws that oversee government health plans such as Medicare and Medicaid, several state laws also have specific laws to prohibit a provider from waiving patient out-of-pocket costs. For example, a physician in NY who, as a general business practice, waives otherwise applicable co-insurance, co-payments, or deductibles, where such waiver would affect the amount the insurer would pay might be guilty of insurance fraud according to N.Y. Penal Law § 176.05(2) and N.Y. Ins. Law § 403(c). 4 Always err on the side of caution and remember to treat all patients equally.
Linda Walker is the owner of Practice Managers Resource and Networking Community. She has almost 30 years of health insurance and medical claims experience and is focused providing the most up-to-date resources and services to the medical billing industry and promises to deliver the most honest and ethical services to her members. PMRNS is also dedicated to the continued efforts to stop PHI from being accessed or sent outside the U.S. Visit www.billerswebsite.com for more resources.
1 - 42 U.S.C. § 1320a-7b(b Federal Anti-Kickback Statute 2 - 31 U.S. Code § 3729 - False Claims Act
3 - See http://avym.com/wp-content/uploads/2015/03/North-Cypress-Medical-Center-v.-Cigna.pdf 4 - http://ypdcrime.com/penal.law/article176.htm#p176.05
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Practice Management
10 Tips for
Successful Medical Practice Recruiting Who recruits employees or providers for your practice or organization? Many larger healthcare practices or organizations may use an external recruiter or engage local medical societies for help. For smaller practices, you might place an ad, go through a local educational college or university, or get assistance from the hospital HR department. There isn’t much of a difference either way, and many times you might get duplications of résumés.
S
o, what exactly makes the recruiting process successful? The reality is that everyone in your practice or organization—large or small—helps recruit for your organization, and the retention of staff starts with proper recruitment. Setting the tone and expectations early and following through can help mitigate the need to do the search again. Here are 10 tips for successful recruiting: 1. First and foremost, the 1st key is to build your candidate pool before you need it. 2. Look for potential employees on LinkedIn and in other
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social media outlets. Bring your best prospects in to meet them before you need them. 3. Plan. Identify both current and future needs; determine your financial resources, personnel resources, and marketing resources. 4. Start the process early. If you wait until a position is vacant, you are already several months behind schedule. 5. Watch the online job boards for potential candidates who may have résumés online even if they’re not currently looking.
6. Understand the market. What is the going rate for your position? What are the benefits you need to offer to attract the right candidates? 7.
Understand the organization’s culture, knowing this will help you get the right fit.
8. Manage the process. Clearly communicate your expectations, practice culture, and compensation packages. 9. Engage your physicians and other team members and prepare them. Help them identify what to ask during interviews with a standard list of questions, as well as a report form to complete after the interview 10. Be organized. Have a tracking system that shows where you are in the process, and when you have found “The One,”
move quickly. The quote, “Time kills all deals,” is true when it comes to your ideal candidate. Practicing quality medicine while maintaining and managing the bottom line is a balancing act that providers face daily. The Physicians Practice S.O.S. Group is committed to helping healthcare providers across the country with new practice startups, IRO needs, and providing practice management and compliance solutions. Call our office to discuss any needs you might have.
Regina Mixon is the CEO of The Physicians Practice S.O.S. Group and is committed to helping healthcare providers across the country with new practice startups, IRO needs, and providing practice management and compliance solutions. Call to discuss any needs you might have. www.ppsosgroup.com
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Creating a Culture of
Compliance in 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on “compliance”-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even what they are willing to tolerate. In 2018, you will need to walk through your compliance program and determine how to shift from a compliance-only approach to a “Risk-Based” approach. This will require your compliance team to focus on areas often ignored, those that leave your compliance program exposed to the threats of government agencies, and their investigators. Regardless of the size of your organization, this shift in thinking and in carrying out functions of compliance is a must to ensure you are covering your assets!
Keep in mind we are talking about compliance within healthcare, which is different than any other industry. BC Advantage Magazine
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To set yourself on the right course of how to approach compliance, you have to first define it. Keep in mind that we are talking about compliance within healthcare, which is different than any other industry; when we talk about healthcare compliance, it is important to understand that it is the process of following rules, regulations, and laws that relate to healthcare practices. Healthcare organizations are held to very strict standards, regulations, and laws from the federal and state levels, and violating these can result in lawsuits, significant fines, loss of licenses, and exclusion. The “Filip” Factors and how The DoJ uses these dates back to the Filip Memo of 2008, and even before that, you had the McNulty Memo of 2006. As I am sure you will understand the structure of the laws pre-dates even 2006, dating back to 1999 when Eric Holder was the Deputy Attorney General. The guidelines delineate several factors that focus significantly on whether a corporation has been “cooperative” during the course of a government investigation. This became known as the Holder Memo. The level of cooperation leads to whether to indict the corporation or strike a plea agreement. In January 2003, the Holder Memo was replaced by the Thompson Memo (Deputy Attorney General Larry D. Thompson). The Thompson Memo was modified in December 2006 by Deputy Attorney General Paul J. McNulty, who made several critical alterations based on certain friction points between prosecutors, their corporate targets, and the defense bar, which in some instances had led to contentious battles in the federal courts. This portion is very important, because it set the standard for how future Attorney Generals and their Deputies would advance their agendas. The McNulty Memo altered the treatment of privilege waivers and provision of attorneys’ fees, and added focus on pre-existing compliance programs. The Filip Memo further shifted with regard to what factors drive determinations of whether a corporation deserves “cooperation credit,” which is the standard(s) used to determine whether a corporation would avoid indictment under the guidelines. Where cooperation credit had previously turned on factors including waiver of attorney-client privilege
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or work product protections, under the Filip Memo, it now focused on disclosure of relevant facts. Further, Government requests for disclosure of non-factual attorney-client privileged materials (known under the McNulty Memo as “Category II” information) became expressly forbidden, except in extremely limited circumstances. (In 2015, the Acting Deputy Director Sally Yates created the Yates Memo, which sought to eliminate the Filip Memo and go back to the days of the Wild West in government prosecution.) The McNulty Memo also disallowed as part of the cooperation analysis whether the corporation advanced legal fees to employees, entered into a joint defense agreements, or sanctioned culpable employees. Overall, these changes made it more difficult for the DOJ to conclude that it is appropriate to charge a corporation, and made it easier for a corporation to coordinate and defend itself in a criminal investigation. Again, the Yates Memo of 2015 sought to reverse all of this and thus erode the de-facto attorney client privilege. Since the DOJ has elected to revert back to the Filip Memo, the factors created under this memo are again in effect. The specific Filip Factors include: 1. The nature and seriousness of the offense, including the risk of harm to the public, and applicable policies and priorities, if any, governing the prosecution of corporations for particular categories of crime (see USAM 9-28.400); 2. The pervasiveness of wrongdoing within the corporation, including the complicity in, or condoning of, the wrongdoing by corporate management (see USAM 9-28.500); 3. The corporation’s history of similar misconduct, including prior criminal, civil, and regulatory enforcement actions against it (see USAM 9-28.600); 4. The corporation’s willingness to cooperate in the investigation of its agents (see USAM 9-28.700); 5. The existence and effectiveness of the corporation’s pre-existing compliance program (see USAM 9-28.800); 6. The corporation’s timely and voluntary disclosure of wrongdoing (see USAM 9-28.900);
7.
The corporation’s remedial actions, including any efforts to implement an effective corporate compliance program or to improve an existing one, to replace responsible management, to discipline or terminate wrongdoers, to pay restitution, and to cooperate with relevant government agencies (see USAM 9-28.1000); 8. The collateral consequences, including whether there is disproportionate harm to shareholders, pension holders, employees, and others not proven personally culpable, as well as impact on the public arising from the prosecution (see USAM 9-28.1100); 9. The adequacy of remedies such as civil or regulatory enforcement actions (see USAM 9-28.1200); and 10. The adequacy of the prosecution of individuals responsible for the corporation’s malfeasance (see USAM 9-28.1300). There are also 119 sample questions listed in the “Evaluation of Corporate Compliance Programs,” which are separated into 11
topics: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Analysis and Remediation of Underlying Conduct Senior and Middle Management Autonomy and Resources Policies and Procedures Risk Assessment Training and Communications Confidential Reporting and Investigation Incentives and Disciplinary Measures Continuous Improvement, Periodic Testing, and Review Third Party Management Mergers & Acquisitions
The DOJ’s Fraud Section has found these questions and topics relevant in determining whether to bring charges or negotiate plea and other agreements with entities under investigation. The issuance is the agency’s first formal guidance under the new presidential administration, and the latest effort by the DOJ’s
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“compliance initiative,” which launched in November 2015 with the hiring of compliance counsel expert, Hui Chen. The new guidance is particularly valuable for healthcare organizations in light of the agency’s heightened efforts to prosecute Medicare Advantage plans for fraudulent reporting under the False Claims Act. This document’s main focus is on creating a Risk Based Internal Audit Process (RBIA); it becomes important to understand what this involves. There are six steps of a Risk Assessment Matrix (RAM), in addition to structuring RBIA Policies. There is very good guidance that exists for you to create a Matrix, as well as to structure proper policies. It will, however, take a bit of effort on your compliance team’s part to develop these, but it can be done fairly efficiently without having to spend tens of thousands of dollars to hire an attorney or compliance consultant. Still, there are organizations where even their compliance professional(s) do not possess the understanding or requisite skills to make this dynamic shift, thus requiring help from outside professionals. Just how important is Risk Based Auditing? I tend to take my lead from CMS when it comes to audit risk. In 2011, CMS implemented a new fraud, waste, and abuse detection model called the Fraud Prevention System (FPS). This is how CMS described the FPS in their 2014 report to Congress: The Fraud Prevention System (FPS) is the state-of-the-art predictive analytics technology required under the Small Business Jobs Act of 2010 (SBJA). Since June 30, 2011, the FPS has run predictive algorithms and other sophisticated analytics nationwide against all Medicare fee-for-service (FFS) claims prior to payment. For the first time in the history of the program, CMS is systematically applying advanced analytics against Medicare FFS claims on a streaming, nationwide basis as part of its comprehensive program integrity strategy. Basically, CMS has sent a message to healthcare providers that
says, “We have upped the ante, now it’s your turn.” We are being given more than just a hint to move toward a more sophisticated method for determining which of our claims may be most at risk for improper coding and billing. We are being given a mandate. In fact, in that same report, CMS boasted that they prevented nearly $1 billion in payments from going out, and that doesn’t even address how much they recouped through their chase and pay efforts. What providers need to understand is that 100% of all Medicare fee-for-service claims are now being processed through these predictive algorithms prior to payment. What risk-based auditing does is allow us to see what we look like to those algorithms, so to speak. In essence, if we want to see what the auditors see before they come knocking on our doors. The days of conducting random probe audits and assigning fixed annual chart review requirements have gone with the past. These methods aren’t just inefficient and inaccurate, they are useless. In fact, a case can be made for doing nothing over random probe audits as they most often will miss some 90% of risk opportunities. While methods and algorithms will improve with time, the fact is, risk-based auditing, in whatever final form, is here to stay. The other critical aspect of your compliance program is the coding and documentation of professional services rendered to patients by your providers and how you are defining Medical Necessity and other compliance components. Focus on Medical Necessity; make sure you understand how to define it, and more importantly, how it is defined by CMS and Private Payors. At the end of the day, how you structure your OIG Compliance Program will have significant impact not only on your operations, but how the government looks at you and what their position will be during an investigation as to whether they will structure a plea agreement or proceed with prosecuting the case. Take the time to understand the sample questions broken down by topic under the Filip Memo, as well as how to structure an
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effective Risk Based Internal Audit Process via the establishment of a Risk Assessment, because your compliance programs are no longer solely based on the “Seven Elements” to an Effective Compliance Program.
Sean M. Weiss is a Partner & Chief Compliance Officer. Sean has dedicated his career to helping healthcare facilities reduce the risk of noncompliance and achieve measurable financial results. An accomplished compliance and management professional, Sean has extensive knowledge of the inner workings of government agencies at both the federal and state level, including the Office of Inspector General, Department of Justice, and The United States Attorney’s Office. Sean has been recognized time and again by clients for successfully protecting their organization from unwarranted penalties and ensuring they receive due process. In his medical audit appeal defense work, Sean and his team of auditing and compliance experts have a proven record of success. Sean develops comprehensive, customized compliance plans, and serves as a third-party compliance consultant to ensure that client compliance is absolute.
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Frank Cohen, Director of Analytics and Business Intelligence. Frank Cohen’s areas of expertise include data mining, applied statistics, and predictive analytics. In addition, he provides compliance risk analysis and meaningful assistance to healthcare organizations in the areas of process improvement, compliance, quality, and profitability. Frank works with a wide range of clients, including solo-physician offices to practices with over 1,000 physicians, academic medical centers, cancer clinics, legal and accounting professionals, government agencies, and national associations, such as MGMA and AMA. He and his team have worked with physicians and practices in nearly 60 different specialties and within every state in the U.S. The author of several books, including his newest, “RVUs: Applications for Medical Practice Success,” Frank is a sought-after speaker. He has participated in and published numerous articles and studies and trained thousands of physicians, administrators, CPAs, and other healthcare professionals in all areas of healthcare analytics. His experience also includes eight years as a physician assistant in both the Navy and as a civilian, clinic administrator, and hospital CEO. Frank’s clients appreciate his depth of knowledge and especially his ability to deliver complex analytical findings in terms that medical professionals can put into practical use.
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Practice Management
What is a Legal Hold and e-Discovery Anyway? Whether I am assisting clients or presenting, I am often asked about legal holds and e-discovery. The transition from paper to electronic records, which include emails, computer faxes, protected health information (“PHI”), personally identifiable information (“PII”) and documents that are created, received, maintained or transmitted in an electronic format created the need for specific rules, practices, policies and procedures surrounding these items. All potential evidence in a lawsuit. As such, organizations—whether big or small, for-profit, or not-for-profit—need to appreciate what can be done both proactively and reactively.
be preserved, the preserved information need not be disclosed to other parties, including opposing counsel or the government, without first being appropriately reviewed to be sure that legally privileged information is removed.
T
he scope of these preservation duties is broad. They apply to business-related electronic information wherever it is stored, on a work station, laptop, tablet, smart phone or other handheld device—and including an employee’s home computer. The preservation duties may also impact independent contractors, especially electronic health record companies and IT providers who provide managed and hosted services. Although legal duties require that information must
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Proactivity begins with understanding what legal holds and e-discovery are and how they impact business. Policies and procedures need to be created specifically for legal holds; and, in turn, should relate to the organization’s data retention and destruction policies and procedures. Next, the organization needs to have a conversation with their IT person—both internal and external, to understand the current capacity and costs. Finally, it is vital to have a lawyer who litigates and understands what to do when a directive is issued by a court or other government agency. The purpose of this article is to provide both an overview
of legal holds and e-discovery, as well as provide some context of where they can come into play in a healthcare environment. Legal Hold When a lawsuit is either filed or reasonably anticipated, an organization has a legal duty to take special precautions to prevent the loss of potentially relevant electronic data, as well as data in other forms. Fundamentally, a legal hold, which may be referred to as a litigation hold, is a directive from a court or government agency ordering that data/ documents from a certain period of time not be destroyed.1 Receiving a legal hold does not necessarily mean the recipient is a party to the legal proceeding. Failing to retain the information in the legal hold can result in a finding of “spoliation of evidence.” Spoliation of evidence relates to the destruction of items in an unlawful manner, oftentimes to avoid certain facts from coming to light at trial, at arbitration, or at government administrative proceedings. Once a legal hold is administered, here are some prudent steps that should be taken: 1. Identify the individual(s), departments, and contractors that may possess the relevant data/documents; 2. Identify where the data/documents are located; 3. Send an internal “legal hold” notice to the appropriate people—both internally and externally. It may be prudent to provide a copy of a court order if it is not sealed; 4. Designate a single individual to coordinate these efforts. Ideally, this person should already be identified in the policy and procedures; 5. Assist your company’s attorneys, which could include internal lawyers and external law firms. Be sure
you understand what persons are representing you. Opposing counsel may try to reach out to unsuspecting employees or contractors for information; 6. If necessary, image hard drives, halt the rotation of disaster recovery tapes, take inventories and other related steps; 7. Conduct a preservation compliance check; and 8. Have your counsel as the court to set parameters and determine who is going to pay for the cost of storing the data/documents. 2 The general framework of a legal hold relates to the discovery process in a legal proceeding. The discovery process is best described as the production of certain types of information to an opposing party in a legal proceeding. Discovery takes different forms including depositions, sworn statements, and document production. This is where a legal hold dovetails with discovery and, in particular, e-discovery. e-Discovery Requests Discovery in federal cases is governed by the Federal Rules of Civil Procedure in a civil matter and the Federal Rules of Criminal Procedure in a criminal matter. Local Rules, which are specific to an individual court, are also relevant. For purposes of this article, I am focusing on the Federal Rules of Civil Procedure (“FRCP”). Three of the main FRCP that govern discovery are Rule 26, Rule 30 and Rule 34. FRCP 26 forms the foundation of discovery. Once a complaint is filed and a response is received, FRCP 26(a)(1)(A) governs what must be provided to the opposite party before a discovery request is made.3 As is the case in the law, exceptions do apply and counsel should assess the situation before handing documents over. The timeframe for disclosure is governed by FRCP(a)(1)(C),
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their own coding staff.”
(C) Time for Initial Disclosures—In General. A party must make the initial disclosures at or within 14 days after the parties’ Rule 26(f) conference unless a different time is set by stipulation or court order, or unless a party objects during the conference that initial disclosures are not appropriate in this action and states the objection in the proposed discovery plan. In ruling on the objection, the court must determine what disclosures, if any, are to be made and must set the time for disclosure.4 A Rule 26(f) conference is a meeting between the parties and the judge. FRCP 34, Producing Documents, Electronically Stored Information, and Tangible Things, or Entering onto Land, for Inspection and Other Purposes is referred to in FRCP 26.5 The general provision, FRCP 34(a) stipulates: A party may serve on any other party a request within the scope of Rule 26(b): 1. to produce and permit the requesting party or its representative to inspect, copy, test, or sample the following items in the responding party’s possession, custody, or control: (A) any designated documents or electronically stored information—including writings, drawings, graphs, charts, photographs, sound recordings, images, and other data or data compilations—stored in any medium from which information can be obtained either directly or, if necessary, after translation by the responding party into a reasonably usable form; or (B) any designated tangible things; or 2. to permit entry onto designated land or other property possessed or controlled by the responding party, so that the requesting party may inspect, measure, survey, pho-
tograph, test, or sample the property or any designated object or operation on it. The typical response time is 30 days. This is important because failing to produce the documents can result in additional motions, court orders, hearings, and costs. In reality, much of discovery is collaborative between opposing parties with each side playing “give and take” on certain timing and production issues. The bottom line is that it is important to work with someone well versed in litigation before producing anything. Conclusion The concepts of legal holds and discovery are complex. And, this article was meant to provide a starting point to build upon. Technology, the variety of places that information could be stored, and the related complexities of gathering the information make e-discovery particularly complicated. The best place to start is within the organization; be proactive with substantive policies and procedures and create a culture of compliance. In turn, this can make responding to a request for discovery or a legal hold letter a bit less chaotic.
Rachel V. Rose, JD, MBA, is a Houston-based attorney advising on federal and state compliance and areas of liability associated with a variety of healthcare, legal, and regulatory issues including: HIPAA, the HITECH Act, the False Claims Act, Medicare issues, women’s health, as well as corporate and security regulations. Ms. Rose has been named in the National Women Trial Lawyers Association-Top 25, and has been listed in Houstonia Magazine’s Top Lawyers 2017Healthcare Law. www.rvrose.com
1
William Hubbard, The Discovery Sombrero and Other Metaphors for Litigation, University of Chicago, Chicago Unbound (2015), https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=12139&context=journal_articles. 2 For a good template of a Legal Hold Policy, see University of Oregon, Legal Holds and E-Discovery Guidelines (2017), https://generalcounsel.uoregon.edu/sites/generalcounsel1.uoregon.edu/files/uo_legal_holds_and_e-discovery_guidelines_paper_file_011317_final.pdf. 3 Federal Rule of Civil Procedure 26, https://www.law.cornell.edu/rules/frcp/rule_26 (last visited Mar. 3, 2018). 4 Id. 5
Federal Rule of Civil Procedure 34, https://www.law.cornell.edu/rules/frcp/rule_34 (last visited Mar. 3, 2018).
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leadership support the bill. 3. Providers are fearful the proposal will put physicians at a disadvantage when it comes to contract negotiations. They fear without the threat of high out-of-network charges, providers
Source: beckersasc - Eric Oliver
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Practice Management
Thoughts Had … Lessons Learned© The Business of Medicine This article will provide more of my perspectives on the Business of Medicine, the approaches that can be taken to preserve the IPOP, and to continue to optimize quality care to the US Healthcare Population while keeping the IPOP in business and optimizing compensation to its Providers and return to its Investors. Yes, Medicine is now a real business.
W
hy Do Independent Physicians Fail?
There is no reasonable debate that will come to any conclusion other than that the IPOP has failed, is still failing, and that many “Healthcare Institutionalists” have survived and prospered. I have been asked many, many times over the years what I thought the greatest threat was to the Independent Physician (IPOP). My answer has always been the same: the Physicians! They don’t think like “Businessmen” (including Businesswomen), but think like self-centric individuals. Of course, the Physicians have given me their reasons for their failure and that of the IPOP being due to others, but none of their reasons can be supported by facts. There are “Healthcare Institutionalists” who have also failed for the same reasons that the IPOP has failed. In its simplest explanation, they think (especially Physicians) that healthcare is different than other businesses; it is not. The “Adam Smith Chart” I presented in the last issue encapsulates all the real basic concepts. The fact is that every business is operated 80%-90% by the same Core Business Principles. The business products or services within a specific business, which is within a core products or services industry, is the 10%-20% differentiator. Most “Business Owners” focus on that 10%-20%. However, if you ignore the “Core Business Principles,” you will fail regardless. The 10%-20% “Differentiator” determines “Market Share.” The “Core Business Principles” determines survival or extinction. There have been businesses that had a “Monopoly” that went extinct because they forgot the “Core Business Principles” that got them where they were. I won’t bore you with examples.
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So, The “Core Business Principles” Are What? They are: • Innovate • Aggregate • Facilitate • Agitate (Positive Change & Adaptation As Needed) Rule one: Don’t try to reinvent the wheel. Most “Inventors” fail. Take existing ideas, systems, technologies, and other resources, and be an “Innovator” and use them to meet current and future market demands and changes. I am not going to get into the weeds on the “how to” in this article. There are some basic “Operating Factors” that every IPOP (any business) needs to manage. They are: • Revenue Generating & Administrative Support Space • Business Technology • Business Communications (all types) • Company Team Culture • Customer Centric Culture • Bottom Line Optimization Each one of those could be an article, or a book. The key point is that all of them need to be managed. My Favorite Operations Management Model I will admit that I may be biased because I am an Air Force Veteran. I have always liked Col. John Boyd’s OODA Loop model he developed. He did many, many things, including
a fighter pilot in the Air force. He designed this for pilots on how they should think about flying a mission. It was a non-traditional, contrarian approach at the time. The key focus was learning from the continuous feedback loop, and adjusting your next action to the changing environment. I think it applies to all aspects of life, including the IPOP. We need a contrarian approach now. Physicians are traditionalist and hate change. That is not a sustainable strategy. There is a significant difference in “Implicit” and “Explicit” decision making. Both are needed. Separate article for those. Planning Methodology OK, it’s time for my usual next article checklist. It is designed to start you thinking about an approach and next steps for your IPOP survival. Most Physicians get bogged down in the minutia of operations and ignore the big picture. Physicians like to save a dollar on paperclips and lose hundredes of thousands in potential revenue because they are worried about the paperclips. Micro management will kill mosts businesses, especially if you also happen to be the primary revenue generator for the business. Remember, Physicians have been trained as acute-care problem solvers and not as long-range success planners. Here is the checklist. • Concepts • Vision • Mission
• • • • • •
Strategic Tactical GAP Analysis Management By Objectives Function Over Form Analytics
Conclusion The next article will provide more detail on my perspectives on the Business of Medicine and the approaches that can be taken to develop and preserve the IPOP of the future. As always, I welcome your criticisms (constructive or not) and your insights. I encourage you to email me with your questions at leshepherd@ medbizoncs.com. Thanks for taking the time to read this. See you next issue.
L. E. Shepherd, Jr. MSA, CHBC, is the CEO of MedBizonics, LLC. He is a Certified Healthcare Business Consultant (CHBC) member of the National Society of Certified Healthcare Business Consultants (NSCHBC). He has written extensively on practice, financial, and tax management topics for various medical and dental publications. He has also lectured at medical societies, and taught practice, financial, and tax management courses through university medical and dental schools. He is a veteran of the U.S. Air Force. www.medbizonics.com
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Billing / Coding
My Secrets to
Marketing to Doctors – Part I If you own a medical billing company, you know how hard it is to get in front of a doctor and explain why he or she needs to outsource their billing to you. Sure, they can save time and money by utilizing an outside billing firm that is focused on getting every penny that is due to the practice. And even if they already outsource their billing, you may have unique ways to save them even more money and collect even more of their hard-earned dollars.
B
ut how do you get past the gatekeeper to present your value proposition to the doctor? Or, how do you work with the gatekeeper to help them realize the reasons why you could make their life easier and show them to be the hero by introducing your outsource services to the practice? After working with hundreds of billing company owners and helping them to sign up hundreds of doctors from coast-to-coast, I want to share some of my secrets with you that will help you get as many physician clients as you can handle.
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The first thing that will help you is pretty obvious: Doctors want to do business with professionals. Are you presenting yourself and your company as someone that a doctor would want to do business with? For example, let’s start with your marketing materials. Are they professionally designed and written? Or did you write them yourself? If not, start with a search for a copy writer (www.fiverr.com, www.freelancer.com). Find someone who has a proven history of writing advertising and sales materials that are convincing, factual, and that provide valuable educational information for the office manager and the
physician. Make sure they can provide examples of their past work and see if they have what it takes to engage and convince someone of what they are selling. Next, search for a graphic artist who can take the finished copy and turn it into a professional-looking brochure or flyer. If you have designed your own material and had it printed on your ink-jet printer, I can assure you that it is not making a good impression on the medical staff. Spend the money to have your marketing materials designed and printed professionally. There are many online printing companies that can take a pdf and print it in full-color on nice paper stock and beat anything that you can produce yourself (www.vistaprint.com, www.overnightprints.com). This advice applies to your business cards as well. I can’t tell you how many people try to save money by designing and printing their own business cards and they look like it! Remember, this is the first impression that prospects have of you and your company. Make the first impression a good one. Now, assuming you have professional-looking marketing materials, what is the thrust of your marketing message? Are you just letting medical practices know that you are in the area and have some medical billing for sale? It’s like selling popsicles in the Artic. “No thanks, I already have some ice!” There are only two situations out there: 1) The practice handles the billing themselves in-house, using their own staff and software; or 2) The practice already outsources their billing and thinks they are happy with it. I say “think” because they probably don’t know whether they are getting the maximum amount of revenue that is due the practice; they just assume that everything is fine because they receive checks in the mail each week and so the billing company must be doing a good job, right?
Not necessarily. Depending on whether they use the latest technology, whether they are using the best clearinghouse, and whether they are using best-practice in the follow up of denied claims, these factors determine whether the practice is receiving every penny that is due them. In many cases, the billing company is only collecting 70% or less of the money that is being billed, which means that the practice is leaving 30% of their revenue on the table. They may think this is “normal” because they have heard similar figures from other practices. And, they may justify this because the doctor can always “write off” some of this lost revenue on their income taxes each year. This is why you must adjust your marketing to the reality of what offices are actually facing and make sure that your message addresses these factors. Why would someone change spouses when they think they are at least as good as all the other spouses they know? You must create at least a question in their minds that maybe there is a better spouse out there that could bring them more satisfaction and happiness. Well, anyway, you get the point. Just because what a practice is currently doing is what they have “always done” does not mean that their billing is what it should and could be. Your message needs to break through that mindset and help create just a tiny bit of doubt in their minds about what they are currently doing. And this is your greatest obstacle to marketing to medical practices: contentment with what they are currently doing. No one likes change. And especially if it involves something that could disrupt the workflow in the office. Look, every medical practice has a lot going on every day. Probably the last thing they want to think about is changing their current billing arrangement. Besides, anyone involved in the billing, if they are doing it in-house, is going to be concerned that their job might be in danger. If the billing is outsourced at some point, don’t they become obsolete?
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So this is another hurdle you must figure out how to overcome. What I call the “fear factor.” Not just a fear of losing their job but fear that someone might find out what a poor job they have been doing of collecting all the revenue that is possible. So address those fears right up front. Let the office manager know that you are not there to eliminate someone’s job. You are there to increase the practice’s revenue, save time, and allow those who are doing the billing in-house to reallocate their time to helping the doctor see more patients more efficiently. After all, seeing patients is the only way that the practice can generate revenue. The more patients that can be seen on a daily basis, the more revenue that is generated by the practice. More revenue means everyone is happier since cash-flow is the life-blood of every business. Happier employees means happier patients. And increased revenue means happier doctors (and their spouses). And happier doctors means happier employees. More cash-flow means new equipment, nicer waiting room, more employee benefits, etc. Every challenge in every business can be solved by improved cashflow. And you are the one who can help make that happen. Now, how can you convey that you are the person, your company is the company, that can help the practice increase their revenue and make things go smoother in the day-to-day operations? It all starts with utilizing what I call “educational marketing.” Don’t just “sell” your advantages over the competition. Give value in your marketing efforts. Share news and information about the medical industry, about the changes coming, about the advantages you can offer the practice. Send out a newsletter, create educational handouts to drop by, mail the doctor a book, give the office manager some reprints of articles you have found on things that are happening in the industry. Set up Google News alerts on medical topics and stay up-to-date on what changes are happening (www.google.com/alerts) and you will never be without something of value to share with the office
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managers and doctors you are targeting. As long as you give a link to the original article, feel free to share any pertinent information with your prospective offices. In today’s world, it is all about traffic, so news sites and authors want you to share their articles with others. Be sure to include your contact information on any handouts you give out so the staff sees your name/ logo over and over. It is repetition that will ensure that you are the one they call if and when they do decide to look into outsourcing. You want to make your name and your company name “top of mind” at all times. This is key to a professional image. Another key to a professional image is, of course, your own appearance. Never go out to offices without dressing as professional as possible. You cannot spend too much on your clothing. Having said that for emphasis, here’s a tip: Go to an upscale department store, like Needless Markup, and ask for the business consultant. Have them show you what you need to dress professionally, and then go to a store you can afford and buy the same type of clothing there. Make sure your personal hygiene is appropriate for close encounters with other humans and then put on a smile (see chapter 2 of How to Win Friends and Influence People by Dale Carnegie if you don’t know why a smile is vital to your success. Now read the rest of the book). In Part II, I will go into detail on ways to engage with doctors and blow away any competition from other billing companies in your area.
Patrick Phillips is the Chairman of the Medical Revenue Management Association of America, the nation’s largest network of Certified Medical Revenue Managers (CMRMs). He is Founder and CEO of American Business Systems and is the author of Cash Crunch to Cash Flow and his most recent book, The New Thriving Medical Practice, with Dr. Vicki Rackner. He can be reached at info@absystems.com.
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Practice Management
Hendrick Health Says Investment in Employee Training Pays Off
in Terms of Loyalty and Improved Patient Care Investing in employees through education translates into higher retention, loyalty, and overall performance, says Hendrick Health System, an 11-time winner of the Gallup Great Workplace Award. The leadership’s continuous focus on community and employees sets them apart.
H
endrick Health serves 19 rural counties in Texas, with access to a variety of cutting-edge healthcare services. With a long history in the local community, the system administration has heavily invested in educational opportunities, which enables healthcare providers and other staff members to provide care at the highest skill levels possible. “Hendrick Health is a not-for-profit system. This allows us to assess things with a different set of glasses that
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for-profit entities have, and when we are making decisions, we are based on doing the right thing at the right time for our people, our patients and our employees,” said Marjohn Riney, BA, CMPE, operations manager for Hendrick Provider Network. In 2014, Riney connected with Practice Management Institute to train providers for the transition to ICD-10. Riney said PMI helped her get the project up and running, and together, they launched specialty-specific classes for more than 85 percent of the specialties.
“My biggest thing was training our physicians and mid-level providers, because at that time, we were moving coders from provider offices to a centralized location downtown to form a different department,” Riney stated.
Administration for his efforts to advance health care for more than 30 years. He was quick to share the credit with his team at Hendrick who he said go above and beyond each day to serve the community.
In 2016, she brought PMI trainers in-house to teach 22 separate classes. To fund the training, Riney worked with PMI to secure a Texas Workforce Development grant in partnership with Texas State Technical College.
“Our success as a health institution is due to the commitment and the legacy of our employees. They care about our patients and for each other,” he said in the January/February 2018 edition of Texas Hospitals magazine. This summer, the Texas Workforce Commission will recognize the Hendrick Health/PMI training partnership along with the Texas State Technical College for efforts made by these organizations to bring training opportunities to Hendrick Health employees.
The educational partnership and curriculum is ongoing. PMI will continue to offer unique opportunities for Hendrick staff members to receive the education they need in order to be successful. Fifteen classes will take place in the coming months, focused on medical coding, billing, compliance, management, and front office skills. Both clinical and administrative staffs will have a variety of educational opportunities to choose from. “Hendrick Health knows that when their employees achieve more, it impacts the patient experience in a positive way,” said PMI’s president and CEO, David T. Womack. “Part of providing the best care to patients is making sure every interaction with them adheres to current standards, from clinical visits to billing, and compliance.” A commitment to excellence helps employees across the system advance their knowledge and provide the best care possible to patients. Riney said it has also contributed to employee satisfaction, retention, and loyalty for its physicians, mid-level healthcare providers, and administrative employees. Hendrick Health System President and CEO, Tim Lancaster, received the 2017 Texas Hospital Association’s Earl M. Collier Award for Distinguished Health Care
“This organization goes to great lengths to ensure employees have all the tools for success. It’s exciting to be a part of their educational achievements,” said Womack.
Practice Management Institute provides up-to-date training for outpatient providers and staff. PMI training is recognized by both the Centers for Medicare and Medicaid Services and the Department of Labor for training in medical coding, third-party billing, auditing, office management, and compliance. Live, instructor-led training classes and professional certifications are offered in healthcare systems and hospitals across the country, and more than 20 courses are available on PMI’s website: www.pmimd.com/onlinetraining. For more information on bringing PMI courses to your organization, contact Michael Moore at PMI: mmoore@ pmiMD.com.
PMI National Conference
October 10 - 12 San Antonio, TX PMI’s biggest learning event of the year is all about making you more successful in your office! Sessions will focus on creating new opportunities for growth, address reimbursement challenges, help you navigate new guidelines, and arm you with tools, tips, and professional advice from leaders in practice management. www.pmimd.com/sa18/
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Practice Management
The Department of Justice Softens its Stance on the Applicability of Federal Agency Guidance Documents In a pair of recent memorandums, the United States Department of Justice (Department) signaled a softening of its stance on the application of federal agency guidance documents in affirmative civil enforcement (ACE) cases. The ultimate impact these memorandums will have in the overall health care enforcement space is unclear; however, the memorandums are consistent with the Trump Administration’s goals to streamline regulatory authority. 1
A.
November 16, 2017 Guidance Policy On November 16, 2017, the United States Attorney General sent a Memorandum (hereafter, Guidance Policy) to all components of the Department, which served to clarify the Department’s lawful exercise of power related to federal agency guidance documents.2 In particular, the Attorney General noted that: It [had] come to [his] attention that the Department has in the past published guidance documents—or similar instruments of future effect by other names, such as letters to regulated entities—that effectively
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bind private parties without undergoing the rulemaking process.3 The Attorney General instructed the Department to no longer engage in such practices. Pursuant to the Guidance Policy, Department guidance documents no longer create rights or obligations binding on persons or entities outside of the Executive Branch (including state, local, or tribal governments), and guidance documents no longer create binding standards by which the Department will determine compliance with existing statutory or regulatory requirements.4
To properly effectuate the Guidance Policy, in drafting guidance documents, the Attorney General instructed Department components of the following: •
•
•
•
•
Guidance documents should identify themselves as guidance, disclaim any force or effect of law, and avoid language suggesting that the public has obligations that go beyond those set forth in the applicable statutes or legislative rules. Guidance documents should clearly state that they are not final agency actions, have no legally binding effect on persons or entities outside the federal government, and may be rescinded or modified in the Department’s complete discretion. Guidance documents should not be used for the purpose of coercing persons or entities outside the federal government into taking any action or refraining from taking any action beyond what is required by the terms of the applicable statute or regulation. Guidance documents should not use mandatory language such as “shall,” “must,” “required,” or “requirement” to direct parties outside the federal government to take or refrain from taking action, except when restating—with citations to statutes, regulations, or binding judicial precedent—clear mandates contained in a statute or regulation. In all cases, guidance documents should clearly identify the underlying law that they are explaining. To the extent guidance documents set out voluntary standards (e.g., recommended practices), they should clearly state that compliance with those standards is voluntary and that noncompliance will not, in itself, result in any enforcement action.5
On the other hand, guidance documents are permissible and may be used by the Department when they merely restate existing statutory and regulatory requirements or provide non-binding advice on technical issues by providing illustrative examples.6 In the Guidance Policy, the Attorney General also instructed the Associate Attorney General to work with Department
components to identify guidance documents presently in existence that do not adhere to the principles bulleted above. Such guidance documents should be repealed or modified to comply with the Guidance Policy. 7 Of note, the Guidance Policy concludes by noting that it is intended to be an internal Department policy, and accordingly, “it is not intended to, does not, and may not be relied upon to, create any rights, substantive or procedural, enforceable at law by any party in any matter civil or criminal”8 B. January 25, 2018 Associate Attorney General Memorandum On January 25, 2018, the Associate Attorney General issued a Memorandum (hereafter, Memorandum)9 to the heads of the civil litigating components and United States attorneys, which served to further clarify the Guidance Policy. In the Memorandum, the Associate Attorney General summarized the Guidance Policy and explained that its principles applied not only to the Department’s own guidance documents, but also that Department litigators ought to use such principles as a guide to determine the legal relevance of other agencies’ guidance documents in affirmative civil enforcement (ACE) cases. The Memorandum defined ACE cases as those involving Department civil lawsuits filed on behalf of the United States “to recover government money lost to fraud or other misconduct or to impose penalties for violations of Federal health, safety, civil rights, or environmental laws” (e.g., Civil False Claims Act cases).10 In summary, pursuant to the Guidance Policy and Memorandum, guidance documents now should not be used to create additional binding legal requirements that do not already exist by statute or regulation. In addition, non-compliance with guidance documents should not be used as a basis for proving a violation of a statute or regulation in a ACE case. The Memorandum does not have retroactive applicability; that is, the Memorandum applies to cases brought by the Department after January 25, 2018. Applicability to pend-
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ing cases is discretionary (i.e., “This memorandum applies only to future ACE actions brought by the Department, as well as (wherever practicable) those matters pending as of the date of this memorandum”). 11 Similar to the Guidance Policy, the Memorandum concludes by noting that it “is not intended to, does not, and may not be relied upon to, create any rights, substantive or procedural, enforceable at law by any party in any matter civil or criminal.”12 C. Implications of the Guidance Policy and Memorandum on Health Care Entities In addition to relying upon violations of federal statutes and regulations, federal agencies such as the Office of Inspector General (OIG) and Centers for Medicare & Medicaid Services (CMS) historically have also regularly relied upon guidance documents (i.e., sub-regulatory guidance) in litigating civil False Claims Act cases. 13 The health care industry is replete with sub-regulatory guidance documents, which may or may not be consistent with each other and/or with regulatory authority. Such guidance documents include, but are not limited to, the following: OIG Fraud Alerts, Advisory Opinions and Special Bulletins; CMS Manuals and Coverage Articles; and Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs). Under the Guidance Policy and Memorandum, to the extent one of these guidance documents creates additional requirements that do not already exist by statute or regulation (and do not merely restate existing statutory or regulatory requirements), noncompliance with such guidance document should not be used as a basis for proving a violation of the underlying statute or regulation. However, be warned: Health care entities should not disregard agency guidance documents as no longer important. Noncompliance with such documents may still be used as a basis to deny reimbursement for services rendered (e.g., MAC, Supplemental Medical Review Contractor, Recovery Audit, Unified Program Integrity Contractor audits). Furthermore, the Memorandum is specifically applicable to civil ACE cases; the Memorandum is silent as to the Guidance Policy’s applicability to criminal cases. Conclusion The Guidance Policy and corresponding Memorandum
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signal the Department’s turn away from an overbroad application of federal agency guidance documents in its attempts to prove liability in ACE cases. This increased leniency could prove helpful to a health care entity that finds itself caught up in an ACE case. However, as such guidance documents remain relevant in other health care reimbursement and enforcement situations, health care entities should continue to attend to them with a focus on compliance. Jessica L. Gustafson, Esq. is a founding shareholder of The Health Law Partners, P.C. Ms. Gustafson represents hospitals, health systems, hospices, home health agencies, physicians, and other health care providers and suppliers in an array of health care legal matters. Ms. Gustafson devotes a substantial portion of her practice to representing providers in the Recovery Audit (“RAC”) and Medicare audit appeals process. She also regularly assists clients with compliance and reimbursement matters, overpayment refunds, Medicare enrollment matters, as well as other health care regulatory matters. Ms. Gustafson is a member of the American Health Lawyers Association, American Bar Association (Health Law Section), and Michigan Bar Association (Health Care Law Section). She is actively involved in the ABA Health Law Section, serving as Chair of the Physician Issues Interest Group, a Vice-Chair of the Membership Committee, and as a Vice-Chair of the Editorial Board of the publication ABA Health eSource. She also serves as a member of the Advisory Board to the American College of Physician Advisors. Adrienne Dresevic, Esq. is a Founding Shareholder of The Health Law Partners, P.C. Practicing in all areas of healthcare law, she devotes a substantial portion of her practice to providing clients with counsel and analysis regarding compliance, Stark Law, Anti-Kickback Statute, and compliance related issues. Ms. Dresevic serves on the American Bar Association Health Law Section’s Council, which serves as the voice of the national health law bar within the ABA. Ms. Dresevic also serves as the ABA Health Law Section’s Co-Chair of the Physicians Legal Issues Conference Committee, Vice Chair of the Programs Committee (Executive Leadership), and Vice Chair of the Sponsorship Committee. She is licensed to practice law in Michigan and New York and can be contacted at adresevic@thehlp.com.
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Health
Health at Your Desk:
Better Snacking at Work and Home
Snaccident (n): Eating an entire pizza/box of chocolates/family size bag of chips by accident. When I was working in an orthopedic office a few years ago, we were inundated with drug sales and medical equipment reps supplying us with great lunches or other tasty surprises in order to get faceto-face with the two physicians who worked there. If it wasn’t a Bundt cake or donuts, it was an array of yumminess from Olive Garden, Einstein’s Bagels, or in some cases, PF Chang’s. Every week there would be something brought in for us and it was hard not to resist those temptations, especially when we hadn’t brought in something for ourselves that day. Is this something that happens in your office? It’s really hard to resist when it’s right in front of you. Sigh.
N
ow I don’t know about you, but wearing scrubs at work was not good for me. They were way too comfy and far too easy to “grow into.” I hope I’m not alone in this reflection! The struggle was real as my “freshmen 15” grew into an additional “coding 20” in a matter of a year or two. It wasn’t healthy nor was it fun. I found that I could sit with a pile of authorizations or payments to post and literally gorge on foods without even realizing that I had done it. I would then go home and eat a full meal for dinner and not even think twice about it! I realized that I needed to stop the mindless eating that would occur as I did my work and focus on mindful eating and movement. I started with making better choices about snacking and meals. I paid attention to what I was doing and drank more water. This was important because I had forgotten how thirst can seem like hunger to the body and I was more often than not just dehydrated, not hungry! I started choosing nutrient-dense snacks that provided my body with benefits. I chose freeze-dried fruits and veggies, nuts, hummus with veggies, popcorn (this was a hard one as the smell would permeate through the office and patients would comment), fresh fruit, and most importantly, I reduced sodas and those wonderful calorie-laden coffee drinks from Starbucks. I would premeasure healthier choices in snack-sized bags so that I wouldn’t be tempted
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to knock off the entire bag/box in one sitting. I also started stepping out of the office during lunchtime for fresh air and a brisk walk, and during the day, I would walk over to see colleagues at their desks rather than call or page them if I needed them. This helped me in not sitting at my desk and getting lost in work, as well. It took time, but I saw results. My clothes fit better, I physically felt better, my skin looked better, I stayed fuller longer, and as a result, I was a happier person. It was a win-win all around. Importantly, I took the time to limit my distractions while I was snacking. I would stop working on what I was doing and take the time to eat more slowly and savor the flavor. This helped me relax as well as I didn’t feel rushed all the time.
It was hard, as those of us who find ourselves in a job that requires us to sit for long periods of time fully understand, and I still have struggles to this day, but I’m making better choices in the first place so that I do not have to work that hard again. The following includes ideas for healthier snacking: • Sliced up fruit and veggies: This is a no-brainer as we all know that kids are more inclined to eat “McDonald’s” apples (as we call them in our house) than a whole apple, so why shouldn’t we? By making it more convenient, it is easier to work into our day. You could always make a smoothie with some yogurt and fruit as well. One thing that I have particularly enjoyed is freeze-dried fruit and veggies. They last longer on your desk and don’t require refrigeration. Quality is the key here so look at where they were sourced as some countries do not have the same standards that we have in the U.S. • Protein-rich foods: Items such as unsalted or lightly salted nuts, hummus or bean dips, or boiled eggs make you feel fuller, yet don’t leave you needing to lay down in a food coma afterward. • Whole grain foods: Small servings that are high in fiber yet low in added sugars, saturated fats, and sodium, such as whole wheat crackers, cereal, or popcorn. Limit refined-grain foods. • Drink water: Excessive thirst can seem like hunger to most people, so by drinking water and staying hydrated, your body won’t misidentify your symptoms. Also, many calories are consumed via sodas, juices, or coffees, so either reduce, replace, or remove these from your diet. Think about swapping out half of the glass of juice with seltzer water to reduce calories and add some bubbles to your day! • Dairy: A glass of reduced fat milk, skim milk, or almond/coconut milk can help get you through to lunch or dinner. You could also consider having a yogurt or cheese stick as well. Some healthy snacking tips to consider: • Create your own personal sized snacks: Use snack-bags to create smaller portions rather than keeping items in the packaging they come in. This helps with those moments when you realize you’ve just finished an
•
•
•
entire packet of Thin Mints without even thinking. By premeasuring the amount or making smaller amounts, you can avoid overeating. Chew slower: Enjoy the flavor and texture of the foods you are eating. It takes about 20 minutes for feelings of satisfaction to reach our brain, so by eating quickly, you will most likely eat much more than what your body actually needs. And remember that a snack is not a meal. Decide if you are hungry or thirsty: Again, thirst can mimic hunger pains, so drink water throughout your day to stay hydrated. Think about why you are eating: Are you actually hungry, or are you bored, stressed, sad, or just feeling emotional? Our state of mind can wreak havoc with making poor choices while we eat.
It is not necessary to run out and throw all sugar-laden, high calorie foods/snacks into the trash and dream about them in the throes of a sugar withdrawal coma. We can still have the yummy cakes and other stuff (my weakness is cakes and chocolate!), but just in moderation. Truth be told, we don’t need them every day (my 8 year old daughter may disagree, but thankfully she is not a BCA reader yet!). Our bodies don’t need those empty calories that come in the form of refined sugars, processed foods, white flours, and preservatives, etc. Our health doesn’t either. But sometimes we need those for our soul and we should not always deny that. Just be mindful of how much you’re enjoying! There are many resources available online about healthy snacking, but it is just a matter of making better, mindful choices for ourselves and our families.
*** Health at Your Desk is thrilled to be giving away a selection of Thrive Life freeze-dried fruit and veggie snacks to one lucky BC Advantage reader. *** You can win this awesome and tasty basket by emailing your favorite healthy snack or recipe to Nichole Anderson at nichole@billing-coding.com by Monday, June 18th, 2018. The winner will be notified by email on Tuesday June 19th, 2018.
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New product discounts and
Reviews
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This comprehensive resource covers Incident-to and Split/Shared Services and is delivered immediately as a downloadable eBook (PDF) and includes a one-hour instructional webinar (MP4). Learn how to: • Increase revenue and physician productivity by properly using non-physician providers • Improve both office and inpatient effectiveness by knowing when to use incident-to and split/shared billing • Stay safe from audits by understanding payer-specific rules for incident-to and split/shared billing • Train your staff and providers with the included decision tree, quick-reference cards, and 10-scenario quiz This product includes: • Detailed guide on incident-to and split/shared services, including definitions, place of service rules, supervision requirements, documentation requirements, and Medicare vs. commercial payer rules • Complete list of CMS and payer source documents that regulate incident-to and split/shared services • 10 clinical examples quiz to test your knowledge, including answer key with correct answers explained • Printable PDF decision tree for incident-to and split/shared services Printable PDF quick reference cards that help you determine whether services can be billed incident-to or split/shared 60-minute webinar on auditing incident-to and split/shared services.
Features: Downloadable forms. One copy of each audit form included in appendix, but all forms are downloadable from website. Case studies. Nine different specialties are featured with two case studies each, for 18 total case studies. Checkpoint exercises. Test your knowledge to confirm comprehension of new content. New topics include EHRs, ICD-10 coding, health information management and other issues essential for maintaining compliance. Learn critical auditing fundamentals, read dozens of case studies, use the checkpoint exercises to test your knowledge, and download actual audit forms to help improve your process. New to this edition: NEW – Cases, chapters, direction for electronic health record (EHR) auditing NEW – Chapter on Clinical Documentation Improvement NEW – Downloadable audit forms NEW – Downloadable Audit Analysis Form and Summary Report NEW – Eighteen evaluation and management E/M case studies for the office setting NEW – Surgery audit cases NEW – Other services audit cases (anesthesiology, radiology, PT and E/M other)
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